The Doctors Company Internal
Medicine Closed Claims Study
analyzed 1,180 claims that closed
from 2007–2014. The study found
that the top allegation, representing
39 percent of claims against internists,
was diagnosis related and resulted
from a delay or failure to diagnose.
This finding is consistent with data
published in Improving Diagnosis in
Health Care (National Academies of
Sciences, Engineering, and Medicine),
which found that 34 percent of
nonsurgical specialty claims are
diagnosis related.

diagnose may be viewed as an error include the following:
or lapse in reasoning rather than just
∙∙ Anchoring bias: The tendency
a failure of clinical skill. Therefore,
to rely too heavily on, or
diagnostic accuracy can be improved
“anchor” to, one trait or
with a better understanding of how
piece of information when
to
avoid
pitfalls
in
medical
decision
Physicians fail to diagnose
making decisions—usually
accurately for many reasons. The making.
the first piece of information
dilemma can be understood best
The monograph Improving
or diagnosis that is acquired.
in the context of the complexity of Diagnosis in Health Care characterizes
∙∙ Premature closure: The
clinical medicine. Illnesses present failure to diagnose in terms of two
tendency to apply premature
with an infinite number of variations, types of thinking processes—rapid and
closure to the decision-making
illustrated by the 68,000 ICD-10 slow—and the effects of psychological
process by accepting a
diagnostic codes and 8,000 recognized biases on medical decision making.
diagnosis or treatment before
diseases and syndromes—many of
Type I, or rapid decision making,
it has been fully verified.
which are uncommon. The average involves pattern recognition (heuristics)
∙∙ Overconfidence bias: A
primary care physician diagnoses that allows the clinician to successfully
universal tendency to believe
about 400 different diseases a year and, diagnose and treat most patients
we know more than we do.
every now and then, encounters a rare efficiently. For example, a female
medical condition that he or she may patient with dysuria and frequency
∙∙ Optimism bias: The tendency
have never seen before.
to be overly optimistic by
will most often have an uncomplicated
overestimating favorable and
It is in this context that failure to urinary tract infection.
pleasing outcomes. This can
Type II, or slow decision making,
also be considered a form of
requires recognition by the clinician
denial.
of the possibility of a complex medical
The following illustrations are
problem and the need for careful
taken
from The Doctors Company
thought, a differential diagnosis,
lab and imaging studies, reference Internal Medicine Closed Claims
resources (such as UpToDate), and/ Study.
or consultation with a specialist.
Case One
Recognition of risk factors is essential.
A 53-year-old male presented to
Psychological biases may the hospital with acute chest, epigastric,
undermine accurate diagnosis and and back pain. Risk factors included
see The Doctor’s Dilemma page 15
treatment. Some common examples

Recently, the Department of Health
and Human Services Office of the Inspector
General (“OIG”) published its Work Plan
for Fiscal Year (“FY”) 2017 (“Work Plan”).
The Work Plan is published annually
and describes OIG’s new and continuing
audit and enforcement priorities for the
upcoming year. There is significant overlap
between the FY 2017 Work Plan and OIG’s
previous work plan activities. However, this
article highlights select new and revised
OIG reviews that impact hospitals, nursing
homes, hospices and home health agencies.
Health care providers and organizations of
all types should use the FY 2017 Work
Plan to identify corporate compliance risks,
prioritize audit focus areas and facilitate
program activities.
Hospitals
∙ Hyperbaric Oxygen (“HBO”)

provide active psychiatric treatment
to meet the urgent needs of those
experiencing an acute mental
health crisis. OIG will determine
whether Inpatient Psychiatric
Facilities complied with Medicare
documentation, coverage, and
coding requirements for stays that
resulted in outlier payments.
∙ Intensity-Modulated
Radiation Therapy (Revised) Intensity-modulated radiation
therapy (IMRT) is an advanced
mode of high-precision
radiotherapy. OIG will review
Medicare outpatient payments for
IMRT to determine whether the
payments were made in accordance
with Federal requirements.
Nursing Homes
∙ Nursing Home Complaint
Investigation Data Brief (New)
- All nursing home complaints
categorized as immediate
jeopardy and actual harm must
be investigated within a 2- and
10-day timeframe, respectively.
OIG will determine to what extent

∙

∙

∙

State agencies investigate the most
serious nursing home complaints
within the required timeframes.
Skilled Nursing Facilities (“SNF”) Unreported Incidents of Potential
Abuse and Neglect (New) - OIG
will assess the incidence of
abuse and neglect of Medicare
beneficiaries receiving treatment
in SNFs and determine whether
these incidents were properly
reported and investigated in
accordance with applicable Federal
and State requirements.
SNF Reimbursement (New) Some SNF patients require total
assistance with their activities of
daily living and have complex
nursing and physical, speech, and
occupational therapy needs. The
more care and therapy the patient
requires, the higher the Medicare
payment. OIG will review the
documentation at selected SNFs
to determine if it meets the
requirements for each particular
resource utilization group.
National Background Checks
for Long-Term Care Employees
(Revised) - The Patient Protection
and Affordable Care Act provides
grants to States, through CMS,
to implement background
see Legal Health page 16

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medicaltimesnews.com

1

5/29/2013
7:20:412017
PM
January

Houston Medical Times

Page 4

MD Anderson affirms Surgeon General’s
conclusions on e-cigarette use among
youth and young adults
The University of Texas MD
Anderson Cancer Center fully supports
the United States Surgeon General’s
call to action to prevent the use of
e-cigarettes by our nation’s youth. The
Surgeon General’s Report, released
today, emphasizes that this diverse class
of nicotine delivery devices presents
a significant public health threat that
must be addressed.
“With the staggering amount of
lives claimed by tobacco use each year,
we must make every effort to limit
youth exposure to products that may
lead to lifelong tobacco dependencies,”
said Ronald A. DePinho, M.D.,
president of MD Anderson. “The
Surgeon General’s Report provides
much-needed clarification of short and
long-term health risks of e-cigarette
use by young people and offers sound
recommendations to prevent a new
generation from developing nicotine
addictions.”
According to the Centers for
Disease Control and Prevention (CDC),
e-cigarettes are the most commonly used
form of tobacco among youth, with

rates that have increased significantly in
recent years.

Special Advertisement

Population Sciences. “These devices
are designed to deliver nicotine, an
incredibly addictive drug which is
unsafe for youth in any form. I hope
increased awareness from today’s report
will help reverse the growing popularity
of these devices.”

The Surgeon General’s Report
also reiterates that aerosol produced e-cigarette use and associated harms in
Approximately 16 percent of high by e-cigarettes is not harmless vapor.
our nation’s youth. These include:
school students and 5 percent of Rather, it contains a number of volatile
∙ Raising and enforcing
middle school students reported current chemicals and known carcinogens.
minimum legal-age of purchase
e-cigarette use in 2015, compared to
Advocates of e-cigarettes often
1.5 percent and 0.6 percent in 2011,
for all tobacco products
suggest they may be useful for smokers
respectively.
∙ Including e-cigarettes into
attempting to quit. MD Anderson is
The Surgeon General’s Report strongly supportive of smokers using
smoke-free policies
affirms a strong association between current evidence-based cessation
∙ Regulating e-cigarette marketing
the use of e-cigarettes and conventional methods; however, according to the
∙ Educating the public on the
tobacco products, and research has CDC, there is no sufficient evidence
suggested that e-cigarette use may lead to support that e-cigarettes are safe and
dangers of youth e-cigarette use
to using traditional cigarettes.
effective cessation tools for smokers.
∙ Expanding and improving
Recently, the CDC reported that
Acknowledging the potential
research related to e-cigarettes
American rates of conventional cigarette public health impacts of alternative
“MD Anderson is committed to
use has dropped to an all-time low since tobacco products, the Food and Drug
1964 of 15.1 percent. Still, tobacco use Administration issued new rules ending cancer, and one of the single
remains the leading preventable cause of earlier this year to extend its regulatory most important steps toward that goal is
death in the U.S. and kills an estimated authority over all tobacco products, to eliminate tobacco use,” said DePinho.
480,000 Americans annually.
including e-cigarettes, cigars, hookah “Through our EndTobacco program,
“Though we have made tremendous and other previously unregulated an initiative of MD Anderson’s Cancer
Moon Shots Program, we are supportive
progress in reducing cigarette use in tobacco products.
both adults and children, trends in
The Surgeon General’s Report of any evidence-based policy actions
e-cigarette use are troubling,” said confirms the need for federal regulation to protect our country’s public health
Ernest Hawk, M.D., division head and of these products while proposing especially that of future generations,
vice president, Cancer Prevention and additional necessary actions to prevent from the devastating effects of tobacco.”

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partner,
or just
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Fighting professional burnout: seven ways to take control
By Michael Groat Ph.D.
Menninger Clinic

The challenge of providing ethical,
compassionate, and patient-centered
care can be strenuous. High
patient volume, continuous patient
contact, complex medical needs,
decreased income, the demands
of paperwork, limited coverage for
vacations, government regulations,
and the perfectionistic, workaholic
characteristics of many physicians all
fuel a potentially toxic brew of stress.
Stress, or the heightened emotional
and physical arousal that accompanies
perceived demands, requires adequate
problem-solving to relieve tension.
Most of the time, physicians and health
care administrators find solutions and
manage stress well. When stress piles
up and lingers, however, the ability
to manage stress can deteriorate,
especially as fatigue and the perception

of insurmountable problems increases.
Unresolved stress leads to burnout—a
state of mental or physical exhaustion
caused by excessive and prolonged
stress.
Burnout approaches gradually
and sequentially. Thus, learning to
recognize the stages of burnout can
lead to prevention.
In the early stages of burnout,
symptoms like persistent anxiety,
irritability, headaches, GI upset,
forgetfulness, and insomnia may be
present, signaling states of increased
arousal. As burnout progresses,
efforts to compensate for sustained
stress through energy conservation
take over. Physicians may show late
for work, drink alone and often, use
frequent sleep aids, have less interest
in sex, procrastinate, and spend less
time with colleagues and loved ones.
In the later stages of burnout,
exhaustion peaks. Physicians
can experience chronic mental
and emotional fatigue, persistent
complaints of headaches, stomach
or bowel problems, unhappiness,
tearfulness, loss of interest in work,

Call 713-600-9500
for a free assessment, 24/7.

and social isolation. At worst, the
physician may also entertain suicidal
thoughts as a way of coping with
unbearable misery.
According to various surveys,
31% to 67% of physicians report
having experienced symptoms of
burnout, especially in high demand
fields such as family medicine,
emergency medicine, obstetrics, and
gynecology. And most physicians
report fatigue, demoralization, and
muscle tension as a result of workplace
stress.
Not only does the physician suffer,
but so may the patients. Research
indicates that physician burnout
negatively impacts patient outcomes,

and increases the risk of disruptive
behavior in the workplace (e.g., angry
outbursts).
Seven ways to manage stress and
prevent burnout
From my experience treating
physicians and other professionals, I
recommend the following tips to ease
stress:
1. Re-evaluate priorities: Now’s
the time to make some lifestyle
changes and review your
values. You may decide to go
home earlier one evening a
week and spend rejuvenating
time with friends or family.
Remember what is most
see Mental Health page 16

Physicians are on the medical staff of Behavioral Hospital of Bellaire but, with limited exceptions, are independent practitioners who are not employees or agents of
Behavioral Hospital of Bellaire. The facility shall not be liable for actions or treatments provided by physicians.
Model representations of real patients are shown. Actual patients cannot be divulged due to HIPAA regulations. 162038 6/16

medicaltimesnews.com

January 2017

Houston Medical Times

Page 6

Oncology Research

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Why do some patients respond only to immunotherapy?
By Jorge Augusto Borin
Scutti, PhD
Houston Medical Times

Based on current immunological
developments there is no doubt that
the immune system can recognize
and eliminate transformed cancer
cells. Several studies have investigated
the immune system of cancer
patients, and they suffer from large
immunosuppression mainly due to
decrease lymphocyte proliferation and
cytotoxic activity. This means that

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January 2017

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the immune system, responsible for
immunosurveillance now becomes
weak, inactive and inefficient. Cancer
immunotherapy is one of the best
therapies compared to traditional
therapies that may cause potential
toxicities such as chemotherapy
and radiation. The potential use
of immunotherapy is to restore the
immune system of patients in attempt
to stimulate it to reject and destroy
cancer cells.
Tumor cells are defined as a
heterogeneous and structurally complex
tissue. These cells can recruit diversity
of cell types, including endothelial
cells, fibroblasts and immune cells,
and, through production and secretion
of stimulatory growth factors. This
collection of cells and molecules together
compose the tumor microenvironment.
We know the microenvironment
plays a major role during the

medicaltimesnews.com

initiation and development of tumor
progression. There are some strategies
to modulate the microenvironment
- targeting regulatory cells, blocking
differentiation or recruitment, blocking
immunosuppressive enzymes, regulatory
cell depletion, re-programming
immunosuppressive cells, modifying
the chemokine and cytokine profile
are some examples. The attractively
of new strategies for immunotherapy
is driven by immune response and
microenvironment discovery. Usually,
scientists have relied on conventional
laboratory research tools to identify, for
example, altered genes and changes in
mRNA and protein expression. To put
these cancer biomarkers in the context

the researchers can use several strategies
to find a good parameter to take care
of patient and drug development. Since
Ipilimumab arrived on the scene, a
number of other molecules, such 4-1BB,
TIM-3, LAG-3, OX40, VISTA, GITR
and PD-1 have gathered researchers
attention. Most famous is an antibody
that targets a molecule on immune
cells called PD-1. Data collected from
analysis of tumor tissue can then guide
rational searches for important markers
in the blood. According to Robert et
al 2015 in a scientific article entitled
â&#x20AC;&#x153; Nivolumab in previously untreated
melanoma without BRAF mutationâ&#x20AC;?,
the initial phase I trial with anti-PD-1
(Nivolumab) therapy reported that
PD-L1 expression on tumor cells may
serve as a prognostic marker to suggest
which patients would benefit from
treatment suggesting a correlation
between pre treatment tumor PD-L1
see Oncology Research page 18

Houston Medical Times

Page 7

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medicaltimesnews.com

January 2017

Houston Medical Times

Page 8

Healthy Heart

Smaller Artificial Heart Implanted at Baylor St. Luke’s,
Bringing New Hope to More Patients
Doctors at CHI St. Luke’s
Health–Baylor St. Luke’s Medical
Center (Baylor St. Luke’s) announced
today that they have successfully
implanted the new 50cc SynCardia
Total Artificial Heart (TAH) into a
patient suffering from biventricular
end-stage heart failure. The new device
is a smaller version of its predecessor,
the 70cc SynCardia temporary Total
Artificial Heart, which received FDA
approval in 2004. The patient is the
third person in the country and the
first in Texas to be discharged home
with this smaller artificial heart.
The procedure was performed by
Jeffrey Morgan, MD, Surgical Director,
Mechanical Circulatory Support and
Cardiac Transplant, Texas Heart®
Institute (THI) at Baylor St. Luke’s,
and Chief, Division of Cardiothoracic
Transplant and Circulatory Support,
Baylor College of Medicine. For the
last half-century, the Texas Heart®
Institute at Baylor St. Luke’s has led

January 2017

the world in the push to develop a
viable, durable total artificial heart.
“This device has the potential to
revolutionize the field of artificial heart
technology,” said Dr. Morgan. “Due
to its smaller size, we can now treat
patients who previously could not be
treated with artificial heart technology
and get them back to living a close to
normal lifestyle.”
The 50cc device is designed
to fit patients, smaller in stature,
with life-threatening non-reversible
biventricular (both sides) heart failure.
These patients are typically women
and adolescents who do not have the
body surface area (1.85m² or less) to
receive the 70cc device. With as many
as 100,000 people in the U.S. in need
of new hearts and a little more than
2,500 receiving a transplant last year,
the device is designed to be used
either as a bridge to a donor heart
transplant or for destination therapy,

which provides long-term support to
patients who are not candidates for
transplant.
Similar to a heart transplant,
SynCardia's Total Artificial Heart
replaces both failing heart ventricles
and the four heart valves. In most
cases, SynCardia's heart restores
blood flow, pumping up to 9.5
liters per minute, and eliminates
complications associated with the
patient's failing heart. This helps
vital organs to recover faster and
allows patients to be better transplant
candidates when a donor heart does
become available. As a result, patients
usually see an improvement in their
activity levels and overall quality of
life.

Caption The new 50cc SynCardia Total Artificial
Heart (TAH) is designed to fit patients, smaller
in stature, with life-threatening non-reversible
biventricular heart failure.

The recently implanted patient is
"This device was instrumental a 55-year-old woman who previously
in saving the patient’s life both by had a pacemaker. Other artificial heart
eliminating the symptoms and source devices were too large for her.
of end stage heart failure and acting as
“This is an important step in the
bridge to transplant in someone dying evolution of artificial heart devices,”
from heart failure,” said the patient’s said James T. Willerson, MD,
primary cardiologist Leo Simpson, President, THI. “We’re proud that
MD, FACC, FHRS, FSCAI, Assistant THI continues to lead the way in such
Professor, Baylor College of Medicine technology to help patients.”
and Director of Interventional Heart
Failure, Baylor St. Luke’s.

As part of an initiative by Memorial
Hermann-Texas Medical Center
(TMC) and LifeGift to address the
growing national organ shortage by
raising awareness for the mission while
celebrating those who make the selfless
decision to share the gift of life.
Demand for organs has risen
sharply in recent years, but the
number of organ donors and organs
transplanted has remained relatively
stagnant in the past decade, creating a
widening gap that has lengthened the
waiting list for those who need lifesaving
transplants. There are nearly 120,000
people across the nation on the waiting
list for an organ transplant, and every
10 minutes, a new name gets added to
the list.

the importance of organ donation,”
said Dr. J. Steve Bynon, chief of
abdominal transplantation at Memorial
Hermann-TMC and McGovern
Medical School at UTHealth, who gave
remarks at Friday’s event. “As healthcare
providers, we are committed to saving
lives, and we are beyond grateful for the
thousands of registered organ donors
who help make that possible. We hope
others who have not registered find it
in their hearts this season to make the
decision to join this important cause.”
Dr. Bynon’s remarks were followed
by a moving personal account from
Karen Abercrombie, a Houston woman
whose sister, Julie De Rossi, tragically
perished in a car crash in 2004 and went
on to save many lives through organ

Dozens of attendees gathered together at Memorial Hermann-Texas Medical Center to show off their
Donate Life bracelets in honor of organ donation.

Some recipients wait months, even
years, before a match is found. Sadly, 22
people lose their lives every day before
receiving the call that could save them.
In response to the growing national
crisis, the U.S. Health Resources &
Services Administration has called
on hospitals to play a greater role in
promoting donor registration. Memorial
Hermann-TMC has responded to this
request with a special tribute to organ
donors, donor families and recipients
that was unveiled to the public Friday
morning in the hospital’s Rick Smith
Gallery. The installment, called The
Ultimate Gift, highlights the importance
of organ donation through specially
commissioned portraits of donors,
donor families and recipients which will
be on display for the next several weeks.
In
addition,
Memorial
Hermann-TMC hosted an event
Friday with more than 150 employees,
affiliated physicians, patients and
visitors in attendance, demonstrating
an impressive show of solidarity for the
lifesaving power of organ donation.
“I am so glad we can use the holiday
season – the season of giving – as an
opportunity to raise awareness about
January 2017

medicaltimesnews.com

donation. A year and a half afterward,
Abercrombie’s family discovered that De
Rossi’s tissue donation – specifically her
Achilles tendon – had benefitted NFL
star quarterback Carson Palmer, who is
now with the Arizona Cardinals. Since
her sister’s death, Abercrombie has
become a vocal advocate for organ and
tissue donation.
According to a Gallup Poll, nearly
95 percent of people surveyed say they
strongly support organ donation, but
only about 40 percent of eligible donors
have actually registered in part because of
the myths surrounding organ donation.
In fact, most major religions support
organ and tissue donation; organs can
be donated at nearly any age; and organ
and tissue recovery takes place only after
all efforts to save a person’s life have
been exhausted and death has been
legally declared, according to LifeGift.
“I’ve come to realize that there
are so many misconceptions about
donation that just aren’t true. Through
my sister’s donation, upwards of 80
lives were either saved or enriched,”
Abercrombie said. “Julie was bigger
than life while she was living, and she
has definitely outlived herself.”

UTMB develops an oral vaccine
against Salmonella
Researchers from The University
of Texas Medical Branch at Galveston
have developed a vaccine against
salmonella poisoning designed to be
taken by mouth. The findings are
detailed in an article published in
Frontiers in Cellular and Infection
Microbiology.

to wreak havoc on the digestive system.

“In the current study, we analyzed
the immune responses of mice that
received the vaccination by mouth
as well as how they responded to
a lethal dose of salmonella, said
Ashok Chopra, UTMB professor of
microbiology and immunology. “We
In earlier studies, the UTMB found that the orally administered
researchers developed potential vaccines produced strong immunity
vaccines from three genetically mutated against salmonella, showing their cult intentionally contaminated
versions of the salmonella bacteria, that potential for future use in people.”
restaurant salad bars and sickened
is Salmonella Typhimurium, that were
There is no vaccine currently 1,000 people.
shown to protect mice against a lethal available for salmonella poisoning.
Salmonella is responsible for
dose of salmonella. In these studies, Antibiotics are the first choice in one of the most common food-borne
the vaccines were given as an injection. treating salmonella infections, but the illnesses in the world. In the US alone,
However, oral vaccination is
simplest and least invasive way to
protect people against salmonella
infection. Taking this vaccine by mouth
also has the added advantage of using
the same pathway that salmonella uses

January 2017

fact that some strains of salmonella are
quickly developing antibiotic resistance
is a serious concern. Another
dangerous aspect of salmonella is that
it can be used as a bioweapon – this
happened in Oregon when a religious

the Centers for Disease Control and
Prevention estimates that there are
about 1.4 million cases with 15,000
hospitalizations and 400 deaths
each year. It is thought that for every
reported case, there are approximately

medicaltimesnews.com

39 undiagnosed infections. Overall,
the number of salmonella cases in the
US has not changed since 1996.
Salmonella infection in people
with compromised immune systems
and children under the age of three
are at increased risk of invasive
non-typhoidal salmonellosis, which
causes systemic infection. There are
about one million cases globally per
year, with a 25 percent fatality rate.

Houston Medical Times

Page 13

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January 2017

Houston Medical Times

Page 14

Pharmacy Corner
WHY ARE PRESCRIPTION DRUGS SO EXPENSIVE?
A look at the factors behind why brand name drugs are
expensive—and their price keeps rising
By Christina Sumners

“Brand name drugs, due to the
It’s no secret that the cost of high cost of their development, start
prescription drugs—especially out expensive and then tend to go
brand-name drugs—has been rising up in price every year,” said Lixian
far faster than inflation over the last Zhong, PhD, assistant professor of
few years. This high cost is one reason
that some people aren’t taking the
medication their providers prescribe
for them. It’s not just people paying out
of pocket who are affected. Although
those with good insurance from their
employer or elsewhere may feel the
sting far less dramatically each time
they pick up a prescription, those costs
do eventually trickle out to everyone.
Ultimately insurance companies or
other payers shift some of the burden
to patients in the form of higher
co-payments or deductibles.
pharmaceutical sciences at the Texas
With prescription drug spending A&M Irma Lerma Rangel College of
totaling an estimated $457 billion Pharmacy. “Combine this with other
in 2015, it seems like a good time to
factors affecting the industry, and you
examine why these life-saving and
life-improving medications cost so have ballooning prices.”
much.

January 2017

up the cost of development—which can
The cost of prescription drugs run more than $2.5 billion per drug,
isn’t going up evenly across the board. according to a 2014 estimate. Therefore,
the starting price of these drugs is quite
In fact, the average price of a generic
high.
drug actually went down between 2010
Other drugs—especially the
and 2015. However, the high initial
and increasingly rising prices of brand so-called specialty drugs that treat
name drugs, especially some specialty complex, chronic conditions—also
treatment drugs, bring the overall tend to be very expensive. “For example,
there is a drug to treat hepatitis C that
average up.
is much better than earlier treatments,
“The most expensive drugs tend with a higher cure rate and fewer side
to treat orphan diseases, those with effects,” Zhong said. “However, it also
costs a great deal more than other
hepatitis C drugs on the market.”
Other expensive specialty medications
include new drugs for treating cancer,
rheumatoid arthritis, multiple sclerosis
and other diseases. These easily cost
more than $10,000 a year.
overall average

The price of certain drugs drive up

Even expensive drugs can be
cost-effective

a patient population of less than
200,000,” Zhong said. This makes
a certain amount of sense: the fewer
potential customers who will buy the
drug before the patent expires, the fewer
opportunities the company has to make

medicaltimesnews.com

That expensive hepatitis C drug—
despite its staggering price tag of
$90,000 for 12 weeks’ supply—could
actually be cost-effective if it can keep
people out of the hospital. “Because 90
percent of people who take the drug
are cured, which is far higher than
less expensive treatments, there might
potentially be cost savings in terms of
improved patient health,” Zhong said.
see Pharmacy Corner page 18

Houston Medical Times

Page 15

The Doctor’s Dilemma
Continued from page 1

hypertension, diabetes, tobacco use,
and a family history of coronary artery
disease. An EKG was negative for
acute changes. Lab studies included a
normal CPK and minimally borderline
troponin. The lipase was 1,455, and
a diagnosis of acute pancreatitis was
made. The epigastric pain improved,
but the patient continued to report
lower chest pain associated with chest
palpation. Two weeks after discharge,
he presented with an acute myocardial
infarction.

Discussion

Primary care physicians see many
patients with nonspecific symptoms
of nausea and fever. Most of these
patients have an acute and self-limited
viral illness. However, complaints
of acute visual loss are relatively
uncommon in a general practice, and
most primary care physicians do not
have the training or equipment to
properly evaluate those patients. This
case illustrates overconfidence bias
in which the physician appears to
Discussion
have failed to recognize the potential
The physician correctly diagnosed significance of an unusual visual
pancreatitis but, in retrospect, missed complaint, concentrating instead on
subtle suggestions of myocardial the more common viral illness.
ischemia, including a slightly elevated
Case Four
troponin and persistent, although
A 45-year-old male, febrile,
atypical, chest pain in the setting of with poorly controlled diabetes,
multiple risk factors. The physician was admitted to the hospital with
anchored on the single diagnosis of vomiting and weight loss. Blood
pancreatitis, which led to premature cultures revealed gram-positive cocci
closure of the diagnostic process.
in chains. The patient was discharged
Case Two
A 60-year-old female presented
to the internist with abdominal pain
and rectal bleeding. She was referred
to a gynecologist, who diagnosed a
likely uterine fibroid on ultrasound.
An endometrial biopsy was benign.
Symptoms persisted, and several
months later the internist ordered an
abdominal CT scan that revealed a
malignant rectal mass displacing the
uterus.
Discussion
The internist appears to have
been reassured by the gynecologist’s
finding of benign pelvic disease. This
is an example of premature closure,
demonstrating that when the referral
was made, the thinking stopped. Both
patient and physician want pleasing
outcomes, but a differential diagnosis—
in this case, focusing on the common
causes of rectal bleeding—would have
probably led to a more timely diagnosis
of rectal cancer.

on antibiotics before the final culture
and sensitivity report was available, but
he was readmitted a week later with
hemodynamic decompensation and
fever and diagnosed with mitral and
aortic valve endocarditis. The results
of the prior culture demonstrated
Streptococcus viridans. He underwent
valve replacement, developed severe
left ventricular decompensation, and
died from end-stage congestive heart
failure before a heart transplant could
be performed.

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Discussion
This patient’s initial improvement
appears to have led to another example
of premature closure and optimism
bias. It is, of course, essential to review
final blood culture results and not
make the assumption that the patient’s
initial improvement is a predictor of a
successful outcome.
Case Five

A 59-year-old male admitted with
abdominal pain was diagnosed with
Case Three
acute diverticulitis and treated with
A 65-year-old female presented Garamycin, Avelox, and Flagyl. The
with nausea, fever, and a dark area in patient was discharged on the same
the visual field of the right eye. She three antibiotics without an order to
was diagnosed with a viral infection. monitor serum gentamicin levels.
Four days later, she presented to an Subsequent symptoms of vertigo were
ophthalmologist with the loss of ultimately diagnosed as gentamicin
central vision in the right eye and was vestibular toxicity.
diagnosed with a retinal detachment,
Discussion
resulting in permanent loss of vision.

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see The Doctor’s Dilemma page 16

medicaltimesnews.com

January 2017

Houston Medical Times

Page 16

TD

The Doctor’s Dilemma
Continued from page 15

Texan Dental

cosmetic & family dentistry

Traditional physician education
has emphasized memorization and
“thinking on your feet.” Stopping to
consult with a reliable reference in the
middle of rounds has not been part
of that tradition. No clinician can
possibly know all of the information
required to practice medicine. There
should be a low threshold for reviewing
references to help with diagnosis and
treatment—even for relatively common
conditions such as diverticulitis. This
case provides another example of
overconfidence bias.

2017

Accurate diagnosis and treatment
are often challenging—particularly
in the context of time limitations
and multitasking required in today’s
practice environment. Having a better
understanding of current theories on
how to improve the diagnostic process
may help clinicians reduce errors and
improve outcomes.

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time of purchase. Expires 12/31/2016.
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January 2017

2512 Rice Blvd.

check programs of prospective
long-term-care employees and
providers. OIG will determine
the outcomes and consequences
of state procedures implemented
for long term care facilities and
providers to conduct background
checks on prospective employees
who would have direct contact
with patients.
Hospices
∙ Review of Hospices’ Compliance
with Medicare Requirements
(New) - Hospice provides palliative
care for terminally ill beneficiaries.
When a beneficiary elects hospice
care the hospice agency assumes
the responsibility for medical care
related to the beneficiary’s terminal
illness and related conditions.
OIG will review hospice medical
records and billing documentation
to determine whether Medicare
payments for hospice services
were made in accordance with
Medicare requirements.
Home Health Services
∙ Comparing Home Health Agency

2510 Smith Ranch Rd.

(“HHA”) Survey Documents to
Medicare Claims Data (New) OIG will assess whether HHAs
are accurately providing patient
information to state agencies for
recertification surveys to avoid
scrutiny of potentially unqualified
or fraudulent providers.
SUMMARY
The FY 2017 Work Plan outlines
many of the OIG’s enforcement priorities
and provides significant detail on the
OIG’s audit and evaluation plans. Health
care providers and organizations should
use the FY 2017 Work Plan to identify
potential risk areas to maintain an
effective compliance program. Although
the OIG will remain extremely active, an
organization that understands the risk
areas and prioritizes compliance goals
may experience a decrease in government
scrutiny and enforcement activity.

Mental Health

Continued from page 5
important to you, and live
accordingly.
2. Be alert to red flags:
Many physicians use their
professional capacity to
maintain emotional distance
medicaltimesnews.com

to ignore their own feelings.
Ignoring pain and distress,
however, is like ignoring
messages the brain is trying to
convey to you, especially when
see Mental Health page 18

Houston Medical Times

medicaltimesnews.com

Page 17

January 2017

Houston Medical Times

Page 18

Mental Health

HOUSTON

Continued from page 16

3.

4.

5.

6.

the emotions warrant notice.
Paying attention to signs of
extended stress symptoms can
prevent worsening difficulties
and health problems.
Take care of yourself: Often
times when we are very stressed
our good coping strategies fall
by the wayside. Self-care is vital
even in times of low stress. Eat
right, get enough sleep, take a
walk or do something else that
rejuvenates you.
Share your concerns with
others: Knowing you’re not the
only one stressed and talking
through ways to reduce even
minor stressors can help.
Take time out from the
situation: Give yourself
permission to let problems go
for a while. Allow time to rest,
play, and relax.
Tackle problems in small
steps: Huge problems are
made easier when broken

down. Taking things one day
at a time helps ground us
in the present, and keeps us
from ruminating on future
uncertainties or past regrets.
7. Know your limits: Knowing
our limits allows us to protect
our time, our interests, and
our health. When demands
mount, no one is going to
send us home. We have to
be our own advocate, and be
willing to assert when enough
is enough.
If stress or anxiety is overwhelming,
causing significant distress or
impacting your daily functions at
work or home, professional help may
be needed. Granted, physicians are
used to being in charge and solving
others’ problems, but at Menninger
we recognize that they are often very
reluctant to seek help.
Personal pride, feeling overly
responsible, fears of stigma and
embarrassment, and excessive
independence all contribute to

difficulties with slowing down
and fighting the ravages of stress.
Preventing burnout is not a chance
event. Physicians can fight back by
recognizing signs of trouble early and
regaining control again.

Published by Texas Healthcare
Media Group Inc.

About the author: Psychologist
Michael Groat is program director of
The Menninger Clinic’s Professionals
in Crisis inpatient program, which
works with medical caregivers,
executives, business owners,
attorneys, administrators, and others
in professions with high levels of
responsibility. The professionals in
the program suffer from the effects of
psychiatric and/or addictive disorders,
as well as stress or other personal
health issues. The Menninger Clinic
is a national psychiatric center for
treatment, research and education,
located on a new campus at 12301
Main St. southwest of the Texas
Medical Center. Menninger is also a
primary teaching hospital of Baylor
College of Medicine.

Director of Media Sales
Richard W DeLaRosa

Continued from page 6

cell populations and response in clinical
trials. They will be dedicated to support
immune monitoring during novel
cancer immunotherapy, being essential
for characterizing the immune status in
patients receiving immune-modulating
therapies such as levels of serum
cytokine, cancer biomarkers on tumor
samples, microenvironment, status of
T cell activation, Natural Killer cells
(NK), presence of immunosuppressive

profile – T regs and MDSC (Myeloidderived suppressor cell) and some
molecules like IDO (indoleamine 2,3
dioxygenase), Galectin among others. A
harmonized struggle to assess the value
nongenetic biomarkers that address
different aspects of the cancer-immunity
cycle in T cell checkpoint blockade will
allow us to integrate information on
individual aspects of tumor-immune
interaction.

Pharmacy Corner
Continued from page 14

“When you consider the cost of the
average hospital stay—which varies by
state but easily runs several thousand
dollars per night—then $90,000 to cure
a patient doesn’t seem as extreme.”
The listed price isn’t what people
actually pay
Very few patients actually pay
the “sticker” price of a drug. Many
people have insurance, and insurance
companies manage their own costs by
negotiating with the drug companies.
The pharmaceutical manufactures
themselves often have patient assistance
programs that cover much or all of the
cost for those people without insurance.
January 2017

Many also offer vouchers or coupons to
reduce the out-of-pocket cost of the drug
for people who have coverage.
Americans subsidize the cost of
drug development
“We cannot look at this problem
without looking at the whole health
care system, which is fragmented in
the United States with many different
payers,” Zhong said. “Countries with a
single-payer system tend to have more
negotiating power, so we pay more
than other countries, often by quite a
bit. On the other hand, those countries
may limit the access to new medications
due to economic concerns.” The end

Oncology Research
expression and clinical response. In
another study tumor samples with
PD-L1 positive had an objective
response rate of 36% (9 of 25 patients)
whereas tumors with PD-L1 negative
didn’t show any objective clinical
response (0 of 17 patients). From
now on, it is going to be more often
the presence of specialized laboratories
doing translational research – studies
of cellular immunity including assays of

Editor
Sharon Pennington

result is that Americans have access
to the newest treatment but also pay
a higher price to subside the cost of
drug research and development, a
lengthy and inherently risky process
that involves preclinical research and
three phases of increasingly large and
expensive human clinical trials.
“Pharmaceutical companies spend
lots of money on research,” Zhong
said. “Only the very lucky drugs make
it through the entire process and get
on the market, where they can both
treat patients and recoup some of their
development costs.”

medicaltimesnews.com

Editor
editor@medicaltimesnews.com

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